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General NPI Number Information
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NPI Number | 1194000554
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Entity Type | Organization
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Legal Business Name | RICHARD S BRAGG MD PA
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Dates
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Enumeration Date | 10/18/2011
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Last Update Date | 10/18/2011
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Provider Practice Location Address
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Address Line | 580 RINEHART RD SUITE 110
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City | LAKE MARY
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State | FL
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Zip | 32746-1551
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Country | US
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Telephone | 407-805-8989
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Fax |
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Provider Business Mailing Address
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Address Line | 580 RINEHART RD SUITE 110
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City | LAKE MARY
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State | FL
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Zip | 32746-1551
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Country | US
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Telephone | 407-805-8989
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | RICHARD BRAGG
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Credential | MD
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Telephone | 407-805-8989
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | ME0065139
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License Number State | FL
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